Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 13  |  Issue : 2  |  Page : 40-44

Management of hypospadias in a resource-poor setting: The Ibadan experience


Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria

Date of Web Publication20-Apr-2018

Correspondence Address:
Dr. Olakayode O Ogundoyin
Department of Surgery, College of Medicine, University of Ibadan, Ibadan
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njps.njps_5_17

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  Abstract 

Background: Penile anomalies especially hypospadias are one of the most common genitourinary anomalies seen in newborns, and they pose a great deal of psychological stress to their mothers. This study examined our experience in the management of hypospadias.
Patients: and Methods A retrospective study of all patients (Group A) managed for hypospadias from 2004 to 2013 was conducted. Data obtained included patients’ demography, their clinical presentation and management. These were analysed and compared with a similar study (Group B) conducted in this hospital four decades earlier between 1966 and 1977.
Results: Forty-eight patients belonging to Group A had repair of hypospadias in comparison to the 42 patients in Group B. The mean age at presentation in Group A was 2.7 ± 4 years, and the anomaly was discovered at birth in all the patients. In contrary, Group B had 32 (76.2%) patients who presented immediately after birth and 10 (23.8%) patients who were either adolescents or adults (12–36 years) with a mean age of 18.9 years. Anterior hypospadias occurred more commonly in both groups; 10 (20.8%) patients were circumcised in Group A and 4 (9.5%) patients in Group B. Surgical site infection was the most common post-operative complication observed in both groups. The type of surgical repair was observed to have significantly influenced the outcome of surgical repair in patients in Group A (χ2 = 14.13, P = 0.05).
Conclusion: Proper and successful management of hypospadias can be enhanced in this environment with adequate media advocacy directed at prompt recognition of this anomaly and avoidance of circumcision when hypospadias has been identified.

Keywords: Circumcision, hypospadias, media advocacy, newborns


How to cite this article:
Ogundoyin OO, Olulana DI, Lawal TA, Ademola SA. Management of hypospadias in a resource-poor setting: The Ibadan experience. Nigerian J Plast Surg 2017;13:40-4

How to cite this URL:
Ogundoyin OO, Olulana DI, Lawal TA, Ademola SA. Management of hypospadias in a resource-poor setting: The Ibadan experience. Nigerian J Plast Surg [serial online] 2017 [cited 2018 Nov 18];13:40-4. Available from: http://www.njps.org/text.asp?2017/13/2/40/230805


  Introduction Top


The occurrence of a penile anomaly in a newborn is often a source of psychological disturbance to the mother. This is particularly worse in a child with hypospadias, in which there is incomplete development of the urethra, and the meatus is abnormally located anywhere along the ventrum of the penile shaft rather than the tip of the glans penis.[1],[2] Widespread variations in the incidence of hypospadias have been reported across countries, race and ethnic groups. For example, the incidence is 1 in 250 live births in the United States, with the least recorded incidence in Mexico at 0.26 per 1000 live births and the highest at 2.11 per 100 live births in Hungary. The incidence is, however, higher in whites than in blacks,[3] and the condition is more common among those of Jewish and Italian descents.[4],[5] In the African population, there is a paucity of epidemiological studies to determine the incidence of hypospadias. However, an incidence of 1.1% was reported in a study of primary school pupils from southeastern Nigeria.[6] Although the cause of hypospadias is unknown, it has been associated with problems with endogenous testosterone production during foetal development. Other risk factors include the environmental exposure of the foetus to endocrine disruptors and the increasing rate of familial incidence.[1] Genitourinary anomalies are the most common malformations associated with hypospadias; these may include undescended testis, inguinal hernia, pelvi-ureteric junction obstruction and the agenesis of the kidney. Severe hypospadias occurring in the proximal urethra could be misdiagnosed as a disorder of sexual differentiation.[7],[8] It is classified based on the location of the meatus in proximal, middle and distal hypospadias with varying degrees of severity. The treatment is mainly surgical and is aimed at achieving good genitourinary function. The choice of treatment, however, depends on several factors that are peculiar to individual patients and noted at initial presentation in the hospital. Factors such as age at presentation, the severity of the condition, the position of the meatus, the presence of chordee, previous circumcision and associated congenital anomalies are some of the factors that may influence decision making. This study, therefore, presents our experience on the management of hypospadias, documents the challenges of management and compares the pattern of patient presentation and management outcome with a similar study from our centre conducted about four decades ago.


  Patients and methods Top


A 10-year retrospective study of all cases of hypospadias managed in a single tertiary hospital from January 2004 to December 2013 was conducted. Information about the patients’ demography, clinical presentation, and management was retrieved from their medical records, and these were presented as a pro forma. The data obtained from this group of patients (A) was compared with a similar cohort of patients (B) managed for hypospadias in the same hospital over a similar duration of time from 1966 to 1977. The data of the patients belonging to Group B was obtained from a previous publication from the same hospital.[5] In addition, the relationship of some parameters such as the location of urethral meatus, the presence/severity of chordee, preoperative circumcision, the presence of associated congenital anomalies, the age of patients at repair and the method of surgical repair adopted were compared with the outcome of surgical repair. The data so obtained were subjected to chi-square (χ2) analysis together with other data obtained using the Statistical Package for the Social Sciences version 21.0 software (SPSS Inc., Chicago, IL, United States); the level of significance was set at P < 0.05.


  Results Top


A total of 48 patients had repair of hypospadias during the study period from January 2004 to December 2013 (Group A), whereas 42 patients were managed from 1966 to 1977 (Group B). The mean age at presentation in Group A was 2.7 ± 4 years and the anomaly was discovered at birth in all the patients in contrary to Group B, in which 32 (76.2%) patients presented immediately after birth and 10 (23.8%) patients were adolescents and adults (12–36 years, mean − 18.9 years). Of the paediatric patients in Group B, only 4 (9.5%) patients had been circumcised before presentation, whereas 10 (20.8%) patients were circumcised before presentation in Group A, whose mean age at repair was 3.3 ± 3.8 years and all of whom were delivered in peripheral centres and circumcised by community health assistants and nurses. Associated congenital anomalies were observed in 14.6% of the patients in Group A, whereas it was 57.1% in Group B. In Group A, inguinal hernia was observed in 3 (6.3%) patients, undescended testis in 2 (4.2%) patients and ventricular septal defect and the disorder of sexual differentiation were found in 1 (2.1%) patient each. In Group B, cryptorchidism was observed in 8 (19.1%) patients, hydrocoele in 2 (4.8%) patients, testicular hypoplasia in 3 (7.1%) patients and inguinal hernia in only 1 (2.4%) patient [Table 1]. Anterior hypospadias were the most common type of hypospadias observed in Group A (66.7%) in comparison with Group B (42.9%). Of these, coronal hypospadias and glanular hypospadias were 60.4 and 6.3%, respectively in Group B in comparison with Group A, in which coronal hypospadias/distal penile hypospadias were seen in 14 (33.3%) patients and glanular hypospadias in 4 (9.5%) patients. Of the posterior hypospadias, penile and penoscrotal hypospadias were observed in 9 (18.8%) and 6 (12.5%) patients, respectively in Group A, whereas in Group B, 6 (14.3%) patients presented with penile hypospadias and 10 (23.8%) patients had penoscrotal hypospadias. A total of 30 (62.5%) patients presented with associated chordee in Group A, whereas there were 29 (60%) patients in Group B [Table 2].
Table 1: Associated congenital anomalies

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Table 2: Location of the meatus

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All the patients in Group A had surgical repair of their hypospadias in comparison with 28 (66.7%) patients in Group B. In Group A, all but 3 (6.3%) patients had one-stage repair of hypospadias, whereas in Group B, 15 (35.7%) patients had two or more stage repairs. Several methods of repair were used in both groups for one-stage repair. Of these methods, the transverse preputial island flap, Mathieu technique and tubularised incised plate urethroplasty were most commonly used in 14 (29.2%), 14 (29.2%) and 11 (22.9%) patients, respectively in Group A. However, in Group B, Denis Brown and the Byars operations were used. Twenty-four (50%) patients developed one or more post-operative complications in Group A, whereas it was 13 (32%) patients in Group B. Complications found in both groups were similar, and they included surgical site infection, urethrocutaneous fistula, wound dehiscence, urethral stricture and residual chordee [Table 3].
Table 3: Post-operative complications

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In Group A, the relationship of the following parameters with the outcome of surgical repair (complications) was examined, and these included the location of urethral meatus (χ2 =2.66, P = 0.85), the presence of chordee (χ2 = 4.70, P = 0.10), circumcision before repair (χ2 = 0.51, P = 0.48), associated genitourinary anomalies (χ2 = 0.17, P = 0.92), the age of the patients at repair (χ2 = 28.33, P = 0.60) and the type of surgical repair adopted (χ2 = 14.13, P = 0.05). All but the type of surgical repair adopted did not significantly influence the post-operative outcome [Table 4].
Table 4: Relationship of some parameters to the incidence of post-operative complications

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  Discussion Top


Hypospadias remains one of the most common genitourinary anomalies, whose prevalence varies across countries, races and geographical locations with varying time periods.[1],[9] The incidence of hypospadias is said to be increasing in industrialised western countries, and this is believed to be connected with in utero environmental exposure to endocrine disruptors such as pollutants, industrial chemicals and pesticides among other risk factors.[1],[4],[10] We observed that the number of cases studied in both groups were similar despite the reported increasing incidence of hypospadias and an increasing population over the last three decades. The fact that many specialized centres for the management of hypospadias have been established and all the cases studied in both groups were hospital-based may account for this increase. In addition, only 76.2% of the patients in Group B were children compared to Group A, in which all the patients were in the paediatric age group. Low levels of awareness about the occurrence of hypospadias and psychosocial disturbance may have hindered early presentation between 1966 and 1977 in comparison to 2004–2013, when the awareness level is expected to have improved and late presentation in adolescent and adulthood may have become rare. The mean age at presentation in Group A was, however, similar to previous studies in this environment.[3],[10] We, however, think that the inclusion of adolescents and adults in Group B may reduce the rate of post-operative complications, because the penis is expected to have increased in size, thus providing adequate tissue for handling during repair; in addition, tissue destruction would be minimal in comparison with infants and younger children who have less penile tissues for handling. Expectedly, congenital anomalies of the genitourinary system were observed to be the most common associated anomalies in both groups, and these included inguinoscrotal hernias, hydrocoele, cryptorchidism and the disorders of sexual differentiation. Although majority of the patients in both groups were residents within Ibadan and surrounding semi-urban areas, there is no evidence that their parents were exposed to organic pollutants, industrial chemicals and agricultural chemicals, which could have increased the incidence of associated genitourinary anomalies especially the disorders of sexual differentiation in the patients.

The inner preputial skin has been suggested as one of the tissues that can be used to construct a new urethra because of its less hair-bearing nature and its rich blood supply.[11] The relatively higher numbers of patients circumcised before presentation in Group A could be due to the fact that all of them came from peripheral hospitals and health centres, where they were delivered and circumcised immediately by the attending nurses and community health assistants who did not know the value of not circumcising the babies before repair. Therefore, it is advised that advocacy should be made to encourage prompt recognition of hypospadias when present, and circumcision should be avoided in babies with suspected hypospadias by the relevant health workers to present a variety of tissue materials for repair.[3]

The aim of surgical repair is to achieve good functional result and cosmetically acceptable penis. To achieve this, several techniques of repair has been put forward with some being a modification of the others. In addition to this, multistage techniques have been described particularly for posterior hypospadias and in the presence of chordee. The surgical repairs adopted for both groups were both single and multistage repairs. However, we observed that more patients (35.7%) in Group B had multistage repair compared with 6.3% in Group A. A relatively higher proportion of posterior hypospadias in patients of Group B may account for this. Although the choice of one technique of repair of hypospadias over others is dependent on the surgeon’s preference, which could be related to surgeon’s skill and experience, the use of Denis Brown and Byar’s operations to repair hypospadias in patients of Group B was the practice in this hospital at that time. However, modern methods such as meatal advancement glanuloplasty incorporated (MAGPI) described by Duckett and Snyder[12] and the modifications of other methods for repairing hypospadias have become more popular and are currently being used in our centre.

Surgical site infection and wound breakdown with fistula formation were common to both groups. Patients treated in Group A were observed to have a higher incidence of complications compared to Group B; this was particularly observed in patients who had single-stage repair in both groups compared with those with multistage repairs. However, the relationship of some parameters such as the location of urethral meatus, the presence/severity of chordee, preoperative circumcision, the presence of associated congenital anomalies, the age of patients at repair and the method of surgical repair adopted were examined with the outcome of surgical repair. All the methods of surgical repair (P = 0.049) were not significantly related to the outcome of treatment. The non-availability of fine specialized instruments including operating loupes and microscopes in most centres managing hypospadias in low- and middle-income countries (LMIC) and the lack of adequate funds to prosecute treatment may also interfere with the surgical outcome, although this was not examined by either of these studies.


  Conclusion Top


The management of hypospadias is still evolving especially in LMIC in spite of the array of knowledge about its care. It is suggested that adequate media advocacy should be adopted to reduce the incidence of circumcision in patients suspected with hypospadias to have a variety of materials for repair. Efforts should also be directed at reducing the financial burden on the parents of infants and children (who pay out of pocket to access medical care) with hypospadias and other congenital malformations to encourage them to present promptly to the hospital and improve outcome. We also suggest that surgeons should use techniques appropriate for the different types of hypospadias to achieve good cosmetic and functional outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
Salako AA, Olajide AO, Sowande AO, Olajide FO. Retrospective analysis of Mathieu’s urethroplasty for anterior hypospadias repair in circumcised children: A single center experience. Afr J Urol 2011;17:11-4.  Back to cited text no. 2
    
3.
Olajide AO, Sowande AO, Salako AA, Olajide FO, Adejuyigbe O. Challenges of surgical repair of hypospadias in Ile-Ife, Nigeria. Afr J Urol 2009;15:96-102.  Back to cited text no. 3
    
4.
Källén B, Bertollini R, Castilla E, Czeizel A, Knudsen LB, Martinez-Frias ML et al. A joint international study on the epidemiology of hypospadias. Acta Paediatr Scand Suppl 1986;324:1-52.  Back to cited text no. 4
    
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Ofodile FA, Oluwasanmi JO. Hypospadias in Nigeria. Plast Reconstr Surg 1978;62:89-91.  Back to cited text no. 5
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6.
Okeke A, Okonkwo C, Osegbe D. Frequency of hypospadias, abdominal and penoscrotal abnormalities among primary schoolboys in a Nigerian community. Afr J Urol 2003;9:56-64.  Back to cited text no. 6
    
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Bhat A. General considerations in hypospadias surgery. Indian J Urol 2008;24:188-94.  Back to cited text no. 7
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Hayashi Y, Kojima Y. Current concepts in hypospadias surgery. Int J Urol 2008;15:651-64.  Back to cited text no. 8
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Murphy JP. Hypospadias. In: Holcomb GW III, Murphy JP, editors. Ashcraft’s Pediatric Surgery. 5th ed. Philadelphia: Saunders Elsevier; 2010. p. 775-90.  Back to cited text no. 9
    
10.
Aisuodionoe-Shadrach OI, Atim T, Eniola BS, Ohemu AA. Hypospadias repair and outcome in Abuja, Nigeria: A 5-year single-centre experience. Afr J Paediatr Surg 2015;12:41-4.  Back to cited text no. 10
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11.
Hinman F Jr. The blood supply to preputial island flaps. J Urol 1991;145:1232-5.  Back to cited text no. 11
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12.
Duckett JW, Snyder HM. The MAGPI hypospadias repair in 1111 patients. Ann Surg 1991;213:620-5.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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